1255459780 NPI number — BILLY LEE BERRY MARRIAGE FAMILY THER

Table of content: BILLY LEE BERRY MARRIAGE FAMILY THER (NPI 1255459780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255459780 NPI number — BILLY LEE BERRY MARRIAGE FAMILY THER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
BILLY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MARRIAGE FAMILY THER
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255459780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
332 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-634-9408
Provider Business Mailing Address Fax Number:
812-482-6712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
332 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-634-9408
Provider Business Practice Location Address Fax Number:
812-482-6712
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 33003623A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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